Received 2022-01-05

Revised 2022-03-14

Accepted 2022-04-10

 Correspondence to: Fatemeh Zahra Memar, International Campus of Shahid Sadoughi University of Medical Science, Yazd, Iran Telephone Number: +989360718656 Email Address: memar_fateme@yahoo.com

Introduction

Cardiovascular diseases (CVDs) are the leading cause of death in women worldwide [1]. Cardiac rehabilitation is a set of interventions necessary to achieve the best physical, psychological, and social conditions [2]. Sexual function is explained as a person's physiological responses to sexual arousal, including sexual desire, excitement, orgasm, and resolution [3]. Notably, 60-78% of patients with CVDs report sexual problems
[4, 5]. However, it seems that patients with stable mild symptoms and good functional capacity are not at risk [6]. One of the counseling needs of patients with CVD is how to resume sexual activity. Although international guidelines recommend that all patients with CVDs need to receive sexual counseling, this is not fully provided by health professionals [7]. Improving patients' conditions with CVDs requires attention to their sexual health. However, cultural, religious, and social taboos may prevent patients from disclosing their sexual concerns [8]. Various pharmacological and psychological therapies have been employed in women with CVDs [9-12].

The most appropriate intervention for the treatment of sexual disorders among patients with CVDs is counseling [13]. Albert Elis introduced one of the most popular and cost-effective methods of counseling as rational-emotional-behavioral therapy (REBT) [14]. It is supposed that these events do not directly induce emotions and behaviors. Instead, it is the individual's beliefs about events that lead to emotional and behavioral functions, the main purpose of which is to enable clients to seek a more realistic philosophy of life, insights into irrational beliefs, and replace them with rational ideas to reduce their disorientation [14]. Fear and stress are among the most critical reasons for the decline in sexual activity in women with CVDs [15].

Regarding the irrationality of the fear and stress of sexual intercourse in women who are undergoing cardiac rehabilitation and have adequate heart capacity for sexual intercourse [16], it seems that this technique proves helpful in improving their sexual function. In recent years, smartphone users worldwide have increased significantly, and online sexual counseling has become highly popular among Asian women [17]. Women with CVDs are at high risk for Coronavirus disease 19 (covid-19), and distance counseling interventions are therefore of particular importance to them [18-20]. Given the importance of sexual function in women with CVDs, the effect of the covid-19 pandemic on domestic violence, high-risk sexual behaviors, marital incompatibility [21-23], lack of enough patient awareness, inadequate counseling by care providers, the existence of contradictory results in research [6, 16], lack of integration of sexual rehabilitation as a routine measure in cardiac rehabilitation in most services [24], and limited studies based on REBT in sexual rehabilitation in women with CVDs, the need for more studies in this field can be one of the research priorities. Also, considering that the issues of sex are regarded as somewhat taboo in Iranian culture by some women, their husbands, or both, studies on women's cultural acceptance, privacy, applicability, and effectiveness of counselling interventions on women's sexual function undergoing cardiac rehabilitation are restricted [25]. The aim of the study was to compare the effectiveness of REBT online versus telephone counseling on sexual function in women undergoing cardiac rehabilitation.

Materials and Methods

Subjects and Randomization

This randomized clinical trial study was performed on women who registered in the cardiac disease registry system in Afshar Hospital from March to July 2021. Subjects were recruited via a telephone call based on inclusion and exclusion criteria. Then, they were randomly assigned into two groups (online vs. telephone) using
http://www.randomization.com. The two groups were again randomly divided into four subgroups (12 women in each subgroup).

Sample Size Calculation

The sample size was estimated based on a previous study by Haji Mohammad Hoseini [26], considering α=0.05, β=20, σ=3.25, and the minimum mean difference of 2 units with a 95% confidence level. With the power of 80% and a 10% drop in the sample size, 24 patients were needed in each group.

Inclusion and Exclusion Criteria

Women with reading and writing literacy, internet and mobile literacy, and ages less than 50 years were enrolled in the study. Also, exclusion criteria included pregnancy, concurrent participation in another study, history of other chronic mental and physical disorders, and use of other drugs except drugs administrated by the cardiologist.

Occurrences of divorce, pregnancy, absence in more than two counseling sessions, incomplete filling of questionnaires, and discontinuing cardiac rehabilitation during the study were considered as withdrawal from the study.

Data Collection

Demographic data were collected through an electronic link in the online and telephone interview in the telephone groups. Also, the Female Sexual Function Index (FSFI) [27] was applied for assessment of the sexual function of women at baseline, end of 8th and 12th weeks. FSFI includes 19 questions that measure sexual desire, arousal, moisture, orgasm, satisfaction, and sexual pain in six independent areas. Based on the weighting of the fields, the minimum and maximum scores for each field were two and six, respectively. Also, the score for the whole scale was 36. FSFI has r=0.74–0.87 and Cronbach alpha=0.90-0.96 [28], and the validity of its Persian version was evaluated by Mohammadi et al. [29].

Intervention

REBT counseling sessions based on relevant sources [14, 30-32] were conducted as individual counseling in eight sessions with an average time of 60 minutes and the same content for both groups (Table-1). In the online consultation group, WhatsApp software provided verbal chat, photos, videos, and the same content was also provided verbally for the telephone group. A reminder SMS was sent to them before each session. In each session, besides reviewing the assignments given to the participants in the previous session, they were asked about the effectiveness of counseling and how far they had improved; they were also asked to discuss the changes they experienced in their sexual function based on the content of the sessions.

Ethical Issues

This study was approved by the ethics committee of Shahid Sadoughi University of Medical Sciences (approval code:
IR.SSU.REC.1399.205) and registered in the Iranian clinical trial registration system (code: IRCT20201222049797N1). Also, informed consent was taken from all subjects before the study.

Data Analysis

All the statistical analyses were performed via SPSS software (version 23, SPSS Inc, Chicago, IL, USA). Data were presented as mean±standard deviation (SD) and/or number and percent. The normal distribution of variables was asses by the Shapirovilk test. Also, Independent Sample t-test was used to determine the difference between the mean scores of FSFI between the two groups of online and telephone counseling. A P-value less than 0.05 was considered as significant difference.

Results

Totally 77 women who were eligible for the study were evaluated, and finally, 48 of them were enrolled (Figure-1). One woman in each group did not complete all the sessions, and final analyses were performed on 23 women. The demographic characteristics of women in the two groups are shown in Table-2. There was no significant difference between age, occupational status, duration of disease, type of treatment, and level of education among online and telephone groups (P>0.05). As the showed in Table-3, the mean FSFI score in the eighth week in the online group was significantly higher than the telephone group (P=0.038). Moreover, a significant difference was identified between the FSFI scores in the follow-up (week 12th) between the two groups of online and telephone counseling (P=0.002). Also, the FSFI scores of the two groups were significantly different between baseline and the end of week 12th (P=0.015). Indeed, women in the online group have a higher FSFI score compared to telephone groups.

The mean scores of all subscales of desire, arousal, vaginal moisture, orgasm, satisfaction, and sexual pain in each group were significantly different at baseline compared to week 12th (P<0.05, Table-4).

Discussion

In this study, the mean score of FSFI of online versus telephone counseling based on REBT among women who were undergoing cardiac rehabilitation was compared, and the results indicated that the scores at the end of weeks 8th and 12th were significantly higher than the baseline of the study. Sahin et al. revealed that the benefits of the REBT-based model on cognitive regulation of emotion in patients with multiple sclerosis [33]. Also, Grove et al. detected that the REBT approach effectively reduced anxiety, depression, and guilty in post-traumatic stress disorder in veterans [34]. Additionally, Kabadi et al. reported the effect of this approach in reducing anger and elevating happiness in women [35]. The reason for the effectiveness of REBT seems to be pertinent to the mechanisms of this type of counseling method in which it identifies irrational beliefs, evaluates the links between cognition, emotion, and behavior, and replaces irrational beliefs with realistic changes [14, 36]. Irrational thoughts in women with CVDs induce reactive emotions, maladaptive behaviors, cognitive defects, trigger catastrophe, and sexual isolation.

On the other hand, their husbands' pressure to have sex causes guilt, worthlessness, and lack of sexual efficiency [37-39]. This attitude in women contributes to irrational fear and anxiety around sex causing them not to run away from it, not yield to it, to take constructive action to solve it, and correct irrational interpretations and frameworks, which reduce their fear and anxiety about having sex [37, 40]. Although both methods of intervention could improve the sexual function of these women, the mean score of FSFI in the online counseling group was higher at the end of the intervention in the eighth and twelfth weeks. Given the effectiveness of online counseling, it seems that individual online counseling for sexual function is culturally acceptable by women, and factors such as lack of violation the privacy, attractive content offered in the form of online chat, videos, and slides on WhatsApp software, the possibility of reviewing the content with the husband, as well as video communication in the chat room leads to a better relationship between the counselor and the patient. Thus assisting them to learn the contents of counseling sessions are better and become more skilled in performing techniques related to improving sexual function [17, 41]. In line with the current study, Farajkhoda et al. evaluated the effectiveness of face-to-face and online counseling with a cognitive-behavioral approach to sexual intimacy of pregnant women and identified satisfaction being accompanied more by the online method [42]. By comparing the effectiveness of online SMS cognitive behavioral therapy and telephone cognitive behavioral therapy on persistent depressive disorder, Raisi et al. reported no significant difference between depression scores in the online and telephone groups [43].

Due to the increase in marital disputes and domestic violence sexual behaviors during the covid-19 pandemic [21-23], it seems that women undergoing cardiac rehabilitation need more sexual counseling. The recovery of patients with CVDs requires attention to their sexual health [8]. Evidence suggests that all patients with CVDs should receive sexual counseling to avoid sexual dysfunction in the form of decreased libido, sexual withdrawal, and ultimately lowered sexual satisfaction of themselves and their spouses [7, 44]. Women under cardiac rehabilitation proved eager to receive information and counseling without a physical presence to reduce the risk of possible transmission of covid-19 [21]. Also, work with a mobile phone equipped with WhatsApp software as it would be easy and attractive for them and provide helpful information; it could be used in cardiac rehabilitation programs to augment sexual activity as an effective method. Pascoal et al. mentioned that online technology-assisted communication is considered as one of the key elements in sexual problems interventions, especially during the covid-19 pandemic [23]. Among the limitations of the present study, we can refer to the concerns of women undergoing cardiac rehabilitation about sexual intercourse due to the prevalence of covid-19 and the fear of being affected by the disease from their husbands working outside; for this problem, other methods of intercourse, which do not involve face-to-face sexual relation were instructed. Another limitation of the study was that blindness was not possible due to the awareness of women undergoing cardiac rehabilitation of the type of intervention, but because the intervention was performed separately, it did not affect women's responses.

Conclusion

REBT counseling, whether online or over the telephone, improved the sexual function of women undergoing cardiac rehabilitation. Online counseling seems to be more acceptable due to the possibility of presenting content in the form of visual chat, reviewing content with the husband, and repeating the review as long as they need to learn emotion regulation skills, and acquire a more realistic philosophy about illness. Also, correct beliefs about sex after heart disease help them to properly use the techniques of sexual intercourse during the covid-19 pandemic and improve their sexual function. Therefore, online counseling can be used in the covid-19 pandemic by observing social distance to improve the sexual function of women undergoing cardiac rehabilitation who are more vulnerable to this disease.

Acknowledgments

We are grateful to the Vice Chancellor for Research and Technology of Shahid Sadoughi University of Medical Sciences for their support and all participants in this study. Also, this study was extracted from the thesis (grant
number: 9423) of Fatemeh Zahra Meamar for the MSc degree in Counseling in Midwifery.

Conflict of Interest

The authors declare no conflicts of interest.

Table 1. Content and Objectives of Rational-Emotional-Behavioral Therapy (REBT) Counseling Sessions

Sessions	Content and objectives
First	Familiarize members with the ABCDE model in everyday life, evaluate activating factors and irrational beliefs, as well as the emotional consequences, identify obligations, and direct them into their preferences so that women with heart disease can understand the adverse consequences of their beliefs around their sexual function
Second	Be able to have the right emotions in difficult life events, reduce anxiety through confrontational whispers, and rational-emotional visualization
Third	Have unconditional self-acceptance and others' acceptance, lack of blame, and feelings of guilt or worthlessness in sex
Fourth	Learn how to talk to themselves internally, challenge or question irrational beliefs, and change the way to express themselves
Fifth	Let go of irrational thoughts by using challenge, Socratic dialogue, book therapy, re-framing, and determining assignments
Sixth	Enjoy desensitization and relaxation techniques, shameless exercises, desensitization
Seventh	Bear sexual self-efficacy, develop constructive behaviors, learn new skills using skills training methods, practice reasonable beliefs, prevent relapse, reinforcements, and punishments with an emphasis on reinforcements.
Eighth	Assess the achievement of goals and measure dependent variables using post-test, prepare references to complete counseling sessions

Figure 1. CONSORT flowchart

Table 2. Demographic Characteristics of Women in the Two Groups

Variables	Online group (n=23)	Telephone group (n=23)	P-value
Age, y (mean±SD)	41.8±5.5	43.2±5.4	0.774
Duration of disease, y (mean±SD)	3.0±1.9	3.5±2.8	0.174
Occupational status, n(%)
Housewife	18(76.2)	20(88)	0.605
Employed	5(23.8)	3(12)
Type of treatment, n(%)
Angiography	14(61.9)	13(72)	0.9
Coronary artery bypass graft	9(38.1)	10(28)
Education level, n(%)
Under diploma	19(76.2)	18(84)	0.449
Above diploma	4(23.8)	5(16)

SD: Standard deviation

Table 3. Mean Scores of Female's Sexual Function Index (FSFI) in Online and Telephone Groups

Variables	Online group (n=23)	Telephone group (n=23)	P-value
FSFI score (mean±SD)
Baseline	13.28±2	12.68±1.52	0.254
Week 8th	28.27±3.18	26.4±2.75	0.038
Week 12th	28.86±2.44	26.6±2.1	0.002
Baseline vs. Week 8th	<0.001	<0.001
Week 8th vs. Week 12th	0.026	0.393
Baseline vs. Week 12th	<0.001	<0.001

FSFI: Female's sexual function index; SD: Standard deviation

Table 4. Mean Scores of the Subscales of Female's Sexual Function Index (FSFI) in the Two Groups

Variables	Online group (n=23)	Telephone group (n=23)	P-value
Sexual desire, (mean±SD)
Baseline	2.3±0.65	1.94±0.68	0.037
Week 12th	3.9±0.52	3.65±0.45
P-value	<0.001	<0.001
Sexual arousal, (mean±SD)
Baseline	2.6±0.62	2.4±0.63	0.051
Week 12th	4.5±0.58	4.1±0.45
P-value	<0.001	<0.001
Vaginal moisture, (mean±SD)
Baseline	1.78±0.26	1.67±0.3	0.01
Week 12th	4.83±0.45	4.31±0.6
P-value	<0.001	<0.001
Orgasm, (mean±SD)
Baseline	1.75±0.34	1.66±0.27	0.024
Week 12th	4.89±0.64	4.58±0.45
P-value	<0.001	<0.001
Sexual satisfaction, (mean±SD)
Baseline	2.9±0.62	2.8±0.61	0.09
Week 12th	5±0.59	4.69±0.37
P-value	<0.001	<0.001
Sexual pain, (mean±SD)
Baseline	1.9±0.71	2.19±0.6	0.334
Week 12th	5.71±0.53	5.28±0.53
P-value	<0.001	<0.001

SD: Standard deviation

References

1. De Marvao A, Alexander D, Bucciarelli-Ducci C, Price S. Heart disease in women: a narrative review. Anaesthesia. 2021;76(Suppl 4):118-30.
2. Bakhshayeh S, Sarbaz M, Kimiafar K, Vakilian F, Eslami S. Barriers to participation in center-based cardiac rehabilitation programs and patients' attitude toward home-based cardiac rehabilitation programs. Physiother Theory Pract. 2021;37(1):158-68.
3. Aghababaei S, Heshmatian T, Roshanaei G, Rohani Mahmoodabadi SM, Refaei M. Sexual Function and Related Factors in Lactating Women with Decreased Sexual Desire referred to Sonqor Health Centers in 2018. The Iranian Journal of Obstetrics, Gynecology and Infertility. 2021;24(2):23-32.
4. Lin CY, Broström A, Årestedt K, Mårtensson J, Steinke EE, Pakpour AH. Using extended theory of planned behavior to determine factors associated with help-seeking behavior of sexual problems in women with heart failure: a longitudinal study. J Psychosom Obstet Gynaecol. 2020;41(1):54-61.
5. Maseroli E, Scavello I, Vignozzi L. Cardiometabolic Risk and Female Sexuality-Part I. Risk Factors and Potential Pathophysiological Underpinnings for Female Vasculogenic Sexual Dysfunction Syndromes. Sex Med Rev. 2018;6(4):508-24.
6. Mornar Jelavić M, Krstačić G, Perenčević A, Pintarić H. Sexual Activity in Patients with Cardiac Diseases. Acta Clin Croat. 2018;57(1):141-8.
7. Murphy PJ, Noone C, D'Eath M, Casey D, Doherty S, Jaarsma T, et al. The CHARMS pilot study: a multi-method assessment of the feasibility of a sexual counselling implementation intervention in cardiac rehabilitation in Ireland. Pilot Feasibility Stud. 2018;4:88.
8. Farquhar JM, Stonerock GL, Blumenthal JA. Treatment of Anxiety in Patients With Coronary Heart Disease: A Systematic Review. Psychosomatics. 2018;59(4):318-32.
9. Kazemi Rezaei SV, Kakabraee K, Hosseini SS. The effectiveness of emotion regulation skill training based on dialectical behavioral therapy on cognitive emotion regulation and quality of life of patients with Cardiovascular Diseases. Journal of Arak University of Medical Sciences. 2019;22(4):98-111.
10. Khodadad Hatkeh Poshti Z, Hassanzadeh R, Emadian S. The Effectiveness of Emotional Schema Therapy on Neuroticism and the Life Style of Cardiovascular Patients. Journal of Babol University of Medical Sciences. 2021;23(1):46-52.
11. Nekonam A, Etemadi S, Pornaghash Tehrani S. The effectiveness of excited family therapy approach on improving Sexual Satisfaction and Marital stress in patients with Coronary artery bypass graft. Journal of psychologicalscience. 2018;17(65):61-77.
12. Richards SH, Anderson L, Jenkinson CE, Whalley B, Rees K, Davies P, et al. Psychological interventions for coronary heart disease: Cochrane systematic review and meta-analysis. Eur J Prev Cardiol. 2018;25(3):247-59.
13. Dos Santos André F, Regina Maria VL. Sexuality of postinfarction patients: diagnosis, results and nursing intervention. J Clin Nurs. 2014;23(15-16):2101-9.
14. Ellis A. The evolution of Albert Ellis and rational emotive behavior therapy. In: Zeig JK. The Evolution of Psychotherapy. 1st Edition. New York: Routledge; 2019. p. 69-82.
15. Nequee F, Oraki M, Janbozorgi M, Alipoor A. The effectiveness of cognitive-behavioral intervention based on stress-induced immunization training on psycho-physiological and psychological characteristics of patients with coronary artery bypass surgery (CABG). Medical Science Journal of Islamic Azad Univesity-Tehran Medical Branch. 2021;31(2):195-204.
16. Byrne M, Doherty S, Fridlund BG, Mårtensson J, Steinke EE, Jaarsma T, et al. Sexual counselling for sexual problems in patients with cardiovascular disease. Cochrane Database Syst Rev. 2016;2(2):Cd010988.
17. Ozaki Y, Nagao K, Saigo R, Tai T, Tanaka N, Kobayashi H, et al. Sexual Problems among Japanese Women: Data from an Online Helpline. Sex Med. 2015;3(4):295-301.
18. Hyde EK, Martin DE, Rieger KL. Factors shaping the provision of sexual health education for adults with acute coronary syndrome: A scoping review. Patient Educ Couns. 2020;103(5):877-87.
19. Rabbe S, Blankart CR, Franz WM, Hager L, Schreyögg J. Impact of a telemonitoring intervention in patients with chronic heart failure in Germany: A difference-in-difference matching approach using real-world data. J Telemed Telecare. 2021:1357633x20984024.
20. Xiao C. A Novel Approach of Consultation on 2019 Novel Coronavirus (COVID-19)-Related Psychological and Mental Problems: Structured Letter Therapy. Psychiatry Investig. 2020;17(2):175-6.
21. Dewitte M, Otten C, Walker L. Making love in the time of corona - considering relationships in lockdown. Nat Rev Urol. 2020;17(10):547-53.
22. Lopes GP, Vale FBC, Vieira I, da Silva Filho AL, Abuhid C, Geber S. COVID-19 and Sexuality: Reinventing Intimacy. Arch Sex Behav. 2020;49(8):2735-8.
23. Pascoal PM, Carvalho J, Raposo CF, Almeida J, Beato AF. The Impact of COVID-19 on Sexual Health: A Preliminary Framework Based on a Qualitative Study With Clinical Sexologists. Sex Med. 2021;9(1):100299.
24. Alavinia SE, Lamir AR, Khajei R, Barjaste Yazdi A. Effect of Cardiac Rehabilitation Program Based on Combined Training on VEGF/Endostatin Gene Expression Ratio in Patients with Acute Coronary Syndrome. Journal of Medical Council of Iran. 2020;38(3):187-93.
25. Ranjbaran M, Chizari M, Matori Pour P. Prevalence of female sexual dysfunction in Iran: Systematic review and Meta-analysis. Journal of Sabzevar University of Medical Sciences. 2016;22(Special Issue):1117-25.
26. Haji Mohammad Hoseini M, Ghanbari Afra L, Ghanbari Afra M, Goudarzi Rad M. Impact of Self-care Educational Program on Sexual Function among Ischemic Heart Disease Patients. Journal of Vessels and Circulation. 2020;1(1):13-8.
27. Rosen R, Brown C, Heiman J, Leiblum S, Meston C, Shabsigh R, et al. The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther. 2000;26(2):191-208.
28. Ryding EL, Blom C. Validation of the Swedish version of the Female Sexual Function Index (FSFI) in women with hypoactive sexual desire disorder. J Sex Med. 2015;12(2):341-9.
29. Mohammadi K, Heydari M, Faghihzadeh S. The female sexual function index (FSFI): validation of the Iranian version. Payesh. 2008;7(3):269-78.
30. Arip M. The effect of REBT Structured Group Counseling towards the psychology aspects of adolescents of divorced parent. Advances in Environmental Biology. 2016;10(4):44-50.
31. Wijayanti A, Sugiharto DYP, Wibowo ME. The effectiveness of rational emotive behavior therapy (rebt) group counseling to reduce cheating behavior. Jurnal Bimbingan Konseling. 2019;8(2):102-7.
32. Zahrakar K, Kasaee A. The Effectiveness of Training Based on Rational-Emotional-Behavioral Therapy on Career Decision-Making Self-Efficacy. International Clinical Neuroscience Journal. 2019;6(2):69.
33. Şahin E, Güleç Keskin S, Terzi M. The effect of a psychoeducation program based on the rational emotional behavioral approach in individuals with multiple sclerosis diagnosis: A randomized controlled trial. Perspect Psychiatr Care (in press). 2021.
34. Grove AB, Kurtz ED, Wallace RE, Sheerin CM, Scott SM. Effectiveness of a Rational Emotive Behavior Therapy (REBT)-Informed Group for Post-9/11 Veterans with Posttraumatic Stress Disorder (PTSD). Mil Psychol. 2021;33(4):217-27.
35. Kabadayi F, Yuksel G. Rational-Emotive Behavior Therapy for Dysfunctional Anger: A Case Study. Journal of Rational-Emotive & Cognitive-Behavior Therapy. 2021;39(4):522-37.
36. Sommers-Flanagan J, Sommers-Flanagan R. Counseling and psychotherapy theories in context and practice: Skills, strategies, and techniques. 3rd Edition. John Wiley & Sons; 2018.
37. Abrams M. REBT and sexual problems. In: Dryden W, Bernard ME. REBT with diverse client problems and populations. Springer Cham; 2019. p. 127-47.
38. Moon JR, Huh J, Song J, Kang IS, Park SW, Chang SA, et al. The effects of rational emotive behavior therapy for depressive symptoms in adults with congenital heart disease. Heart Lung. 2021;50(6):906-13.
39. Murphy PJ, Mc Sharry J, Casey D, Doherty S, Gillespie P, Jaarsma T, et al. Sexual counselling for patients with cardiovascular disease: protocol for a pilot study of the CHARMS sexual counselling intervention. BMJ Open. 2016;6(6):e011219.
40. Grieger R, Alexander KA. REBT with couples. In: Dryden W, Bernard ME. REBT with diverse client problems and populations. Springer Cham; 2019. p. 265-82.
41. Farzandipour M, Farkhian A, Nabovati E, Mir AK, Anvari Tafti S, Rajabi Moghadam H. Smartphone-based application for training outpatient cardiac rehabilitation: Design and usability evaluation. Koomesh. 202;22(4):686-95.
42. Farajkhoda T, Ashrafi F, Bokaie M, Zareei Mahmoodabadi H. Online Compared to Face-to-Face Sexual Intimacy Enhancement Training Program Counseling with Cognitive-Behavioral Approach on Sexual Intimacy in Pregnant Women. J Sex Marital Ther. 2021;47(5):446-59.
43. Raisi M, Jahan F, Moazedian A. Comparison the Effectiveness of Online Text Messenger-Based Cognitive-Behavioral Therapy and Telephone-Based Cognitive-Behavioral Therapy on Persistent Depression Desorder. Rooyesh-e-Ravanshenasi Journal (RRJ). 2021;10(5):139-50.
44. Bagheri I, Memarian R, Hajizadeh E, Pakcheshm B. The effect of sex education on patients and their spouses satisfaction after myocardial infarction. Jorjani Biomed J. 2014;2(1):46-0.